National Vaccine
Information Center

Your Health. Your Family. Your Choice.

MedAlerts Home
Search Results

From the 11/19/2021 release of VAERS data:

This is VAERS ID 965831

Government Disclaimer on use of this data



Case Details

VAERS ID: 965831 (history)  
Form: Version 2.0  
Age: 74.0  
Sex: Female  
Location: Michigan  
Vaccinated:2021-01-18
Onset:2021-01-20
   Days after vaccination:2
Submitted: 0000-00-00
Entered: 2021-01-22
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 012L20A / 1 - / IM

Administered by: Private       Purchased by: ?
Symptoms: Death
SMQs:

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2021-01-20
   Days after onset: 0
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Albuterol Sulfate HFA 108 MCG/ACT AERS Allopurinol 300 MG Oral Tablet Aspirin Low Dose 81 MG TABS Baclofen 10 MG Oral Tablet Bystolic 10 MG Oral Tablet Clobetasol Propionate 0.05 % External Cream Cyanocobalamin 1000 MCG TABS Fish Oil
Current Illness: Emergency Room Visit 1/7/2021 complaining of shortness of breath and swelling. She and elevated D-dimer with no evidence of a Pulmonary Embolus. Persantine Myoview showed small mild area of reversible ischemia to the inferolateral apical wall. Mild symptoms of vague discomfort in her chest, but nothing that has been reproducible with activity. She is chronically short of breath with limited activities because of problems with her hip
Preexisting Conditions: Active Problems Abdominal distention (R14.0) Cellulitis (L03.90) Chronic hip pain (M25.559,G89.29) Chronic UTI (N39.0) Colon polyps (K63.5) Coronary artery disease involving native coronary artery of native heart with angina pectoris (I25.119) Edema, leg (R60.0) GERD (gastroesophageal reflux disease) (K21.9) Gout (M10.9) Left kidney mass (N28.89) Lump of right breast (N63.10) Morbid obesity (E66.01) Neuropathy, diabetic (E11.40) Pain with urination (R30.9) Protein in urine (R80.9) Respiratory crackles at right lung base (R09.89) Type 2 diabetes mellitus (E11.9) Venous (peripheral) insufficiency (I87.2)
Allergies: Allergies: Brilinta, ACE Inhibitors, Bactrim, Cipro, Codeine Derivatives, Penicillins, Statins, sulfa
Diagnostic Lab Data: N/A
CDC Split Type:

Write-up: Patient received her first dose of vaccine on Monday, January 18th. Two days later on Wednesday, January 18th, she retired to bed early. Later that night when her husband went to bed, he found her in the bed deceased. No other details of the event are know.


New Search

Link To This Search Result:

https://www.medalerts.org/vaersdb/findfield.php?IDNUMBER=965831


Copyright © 2021 National Vaccine Information Center. All rights reserved.
21525 Ridgetop Circle, Suite 100, Sterling, VA 20166